Perioperative management - 3-Port VATS Lobectomy Lower Lobe Left

Oncological

• Treatment of choice for patients with histologically confirmed non-small cell lung cancer in UICC Stage I, Stage II, and Stage IIIA (T3N1).
  • According to the new guideline (2022), for patients with a tumor size <2cm or limited cardiopulmonary capacity, an anatomical segment resection can be performed with comparable results. 
• Removal of metastases and unconfirmed central nodules.

Non-Oncological

Limited to the corresponding lobe:

• Infectious lesions such as abscesses, mycetomas, aspergilloma, or cavities
• Post-inflammatory residues (e.g., after tuberculosis)
• Bronchiectasis
• Volume reduction in pulmonary emphysema

• Lack of cardiopulmonary reserve for a lung resection procedure
• General anesthesia intolerance
• Coagulation disorder or use of anticoagulants
  • The permanent use of ASA 100mg does not constitute a contraindication.
  • In cases of higher-grade anticoagulation such as platelet aggregation inhibitors (e.g., Clopidogrel), NOACs (e.g., Xarelto), or Vitamin K antagonists (e.g., Falithrom or Marcumar), an interdisciplinary consultation should develop a therapeutic concept regarding the indication for anticoagulation, the possibility of bridging with Heparin, and the surgical bleeding risk.

• Oncological Diagnostics

In case of suspected bronchial carcinoma, the staging examinations outlined in the guidelines should be performed before any surgery.

• Contrast-enhanced computed tomography of the thorax with upper abdomen
• PET-CT
• MR of the skull
• Bronchoscopy
  • Note: Preoperative bronchoscopy by the surgeon is recommended, especially to recognize anatomical norm variants of the bronchial system.
• Cardiopulmonary Endurance

The assessment of cardiopulmonary endurance and estimation of postoperative outcomes is a very important and sometimes challenging aspect of thoracic surgery. Based on the algorithms of the ERS (= European Respiratory Society) and ESTS (= European Society of Thoracic Surgeons), the following procedure has proven effective:

• Basic diagnostics: Medical history, ECG
  • If there is an indication of increased perioperative cardiac risk ('Revised-Cardiac-Risk-Index"), further cardiological evaluation is necessary.
  • If there is a discrepancy between the anamnesis-based resilience (climbing stairs, gardening, walks) and the parameters of lung function tests, the results should be critically questioned and the examinations repeated if necessary.
• Lung function: Diffusion capacity (DLCO), body plethysmography (FEV1)
  • FEV1 and DLCO >80% of the predicted value allow for surgery up to pneumonectomy from a lung function perspective.
  • FEV1 and DLCO <80% require further diagnostics using spiroergometry and determination of maximum oxygen uptake (VO2max)
    • If VO2max > 20ml/kg/BW (>75%), surgery up to pneumonectomy is possible from a lung function perspective.
    • If VO2max < 10ml/kg/BW (< 35%), surgery is contraindicated.

Especially in cases of VO2max 10-20ml/kg/BW or restrictive cardiac preconditions, an interdisciplinary case-by-case decision with experienced colleagues is essential, in addition to further diagnostics (e.g., perfusion scintigraphy, "lung segment counting").

• Shaving of the left thoracic wall, if necessary
• Single-shot antibiotic with Cefuroxime 1.5g intravenously approximately 30 minutes before the skin incision.

In addition to the general surgical risks such as thrombosis, embolism, allergy, infection, bleeding, and wound healing disorder, specific risks must be clarified:

• Bronchial stump insufficiency, bronchial fistula requiring intervention, possibly also re-operation
• Postoperative air fistula due to lesions of the lung parenchyma
• Postoperative lymph fistula with chylothorax
• Postoperative rebleeding with possibly necessary re-operation
• Conversion to thoracotomy and possibly extension of the resection, approach depending on intraoperative findings
• Injury to adjacent structures, especially the trachea and main bronchi, large vessels, and the esophagus, requiring corresponding extension of the procedure
• Damage to the phrenic nerve with diaphragmatic elevation on the affected side and injury (especially in left-sided surgery) to the recurrent laryngeal nerve with vocal cord paresis on the affected side
• Positioning injuries
• Cardiac arrhythmias

Treatment alternative: In case of oncological diagnosis, definitive radiochemotherapy